RESUMEN
BACKGROUND: Thoracic duct leaks occur in up to 5% of left lateral neck dissections. No one imaging modality is routinely used to identify the thoracic duct intraoperatively. The goal of our study was to evaluate the efficacy and safety of indocyanine green lymphangiography for intraoperative identification of the thoracic duct compared to traditional methods using ambient and evaluate the optimal timing of indocyanine green administration. METHODS: We enrolled all patients who underwent left lateral neck dissection at our institution from 2018 to 2022 in this prospective clinical trial. After indocyanine green injection into the dorsum of the foot, we performed intraoperative imaging was performed with a near-infrared fluorescence camera. We reported the data using descriptive statistics. RESULTS: Of the 42 patients we enrolled, 14 had prior neck surgery, and 3 had prior external beam radiation. We visualized the thoracic duct with ambient light in 48% of patients and with near-infrared fluorescence visualization in 64%. In 17% of patients, we could identify the thoracic duct only using near-infrared fluorescence visualization, which occurred within 3 minutes of injection, and were required to re-dose 5 patients. We visualized the thoracic duct with near-infrared fluorescence in all patients with prior neck radiation and 77% of patients with prior neck surgery. One adverse reaction occurred (hypotension), and 5 intraoperative thoracic duct injuries occurred that were ligated. There with no chylous fistulas postoperatively. CONCLUSION: This trial demonstrates that near-infrared fluorescence identification of the thoracic duct is feasible and safe with indocyanine green lymphangiography, even in patients with prior neck surgery or radiation.
Asunto(s)
Verde de Indocianina , Disección del Cuello , Humanos , Disección del Cuello/efectos adversos , Conducto Torácico/diagnóstico por imagen , Conducto Torácico/cirugía , Conducto Torácico/lesiones , Fluorescencia , Diagnóstico por Imagen/métodos , Imagen ÓpticaRESUMEN
Thoracic duct injuries are very rare due to its protected location. Duct is most often injured in polytraumas and during operations in his vicinity. Treatment is primarily conservative, based on a low-fat diet or parenteral nutrition and adequate chest drainage. If the conservative management fails, a surgical duct ligation via thoracotomy, or more conveniently thoracoscopic approach, is necessary. The presented case reports describe the surgical treatment of isolated injury of the thoracic duct via thoracoscopic approach.
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Quilotórax , Conducto Torácico , Toracoscopía , Quilotórax/cirugía , Humanos , Ligadura , Conducto Torácico/lesiones , Conducto Torácico/cirugíaRESUMEN
Vagus nerve stimulation is a therapy indicated for some patients with medically-refractory epilepsy. Typical risks of this procedure include infection, hoarseness, vocal cord dysfunction, and hardware malfunction. Chyle leak via injury to the thoracic duct is a known complication of thoracic and head and neck surgeries-though less so in the neurosurgical literature. In severe cases, chyle leak can lead to nutritional deficiencies and immunosuppression. Management of chyle leak includes low-fat diet and pharmacological suppression of chyle production with medications such as octreotide. If leak is persistent, surgical exploration with attempted ligation of lymphatic structures is performed.
Asunto(s)
Quilo , Niño , Humanos , Ligadura , Disección del Cuello/efectos adversos , Octreótido , Conducto Torácico/lesiones , Conducto Torácico/cirugíaAsunto(s)
Quilotórax/etiología , Disección del Cuello/efectos adversos , Complicaciones Posoperatorias/etiología , Conducto Torácico/lesiones , Cáncer Papilar Tiroideo/cirugía , Neoplasias de la Tiroides/cirugía , Tiroidectomía , Adulto , Quilotórax/diagnóstico , Femenino , Humanos , Complicaciones Posoperatorias/diagnósticoRESUMEN
Traumatic chylothorax is a rare condition following blunt trauma. Although a chyle leak resulting from direct damage to the duct may occur at any level because of an anatomical variation, an airway obstruction due to thoracic duct injury after blunt trauma has never been described. Here, we report a very unusual case with airway obstruction due to thoracic duct injury after whiplash injury. A 60-year-old man presented to the emergency department with allodynia after blunt trauma. Initial chest computed tomography (CT) showed a prevertebral hematoma and pneumomediastinum from C2 to T3 spinal level without vertebral fracture. Seven days later, repeat CT showed an increased amount of mediastinal and prevertebral fluid collection extending to the upper neck level with airway compression. He underwent an operation to drain the fluid via a neck incision and a thoracic duct ligation via right thoracotomy and was discharged without complaint. The findings suggest that if hematoma and pneumomediastinum are found in the prevertebral space at the level of the cervical and upper thoracic spine, the patient should be closely observed to exclude the complication of airway obstruction caused by thoracic duct injury.
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Obstrucción de las Vías Aéreas , Traumatismos Torácicos/complicaciones , Lesiones por Latigazo Cervical/complicaciones , Quilotórax , Humanos , Masculino , Persona de Mediana Edad , Conducto Torácico/diagnóstico por imagen , Conducto Torácico/lesionesRESUMEN
Chylothorax, although an uncommon complication of esophagectomy, is associated with high morbidity and mortality if not treated promptly. Consequently, knowledge of the thoracic duct (TD) anatomy is essential to prevent its inadvertent injury during surgery. If the TD is injured, early diagnosis and immediate intervention are of paramount importance; however, there is still no universal consensus about the management of post-operative chylothorax. With increasing advances in the spheres of interventional radiology and minimally invasive surgery, there are now several options for managing TD injury. We review this topic in detail to provide a comprehensive and practical overview to help surgeons manage this challenging complication. In particular, we discuss an appropriate step-up approach to prevent the morbidity associated with open surgery as well as the metabolic, nutritional, and immunological disorders that accompany a prolonged illness.
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Quilotórax/etiología , Quilotórax/terapia , Esofagectomía/efectos adversos , Complicaciones Posoperatorias/etiología , Complicaciones Posoperatorias/terapia , Quilotórax/prevención & control , Humanos , Complicaciones Posoperatorias/prevención & control , Conducto Torácico/anatomía & histología , Conducto Torácico/lesionesRESUMEN
Isolated thoracic duct injury is an uncommon clinical event and is rare in the setting of trauma. We describe a case of an isolated thoracic duct injury resulting in the development of bilateral chylothorax following a motor vehicle collision in the absence of any other definable injury. We outline the initial patient presentation and diagnosis. After failing a trial of conservative management the patient underwent lymphangiography followed by thoracic duct ligation with pleurodesis. This case highlights the importance of recognizing thoracic duct injury following trauma.
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Accidentes de Tránsito , Quilotórax/etiología , Conducto Torácico/lesiones , Heridas no Penetrantes/complicaciones , Adulto , Quilotórax/diagnóstico por imagen , Diagnóstico Diferencial , Humanos , Ligadura , Masculino , Pleurodesia , Radiografía , Conducto Torácico/diagnóstico por imagen , Conducto Torácico/cirugía , Tomografía Computarizada por Rayos XAsunto(s)
Implantación de Prótesis Vascular/instrumentación , Prótesis Vascular , Ascitis Quilosa/cirugía , Procedimientos Endovasculares/instrumentación , Disección del Cuello/efectos adversos , Stents , Vena Subclavia/cirugía , Conducto Torácico/cirugía , Ascitis Quilosa/diagnóstico por imagen , Ascitis Quilosa/etiología , Humanos , Masculino , Persona de Mediana Edad , Vena Subclavia/diagnóstico por imagen , Conducto Torácico/diagnóstico por imagen , Conducto Torácico/lesiones , Resultado del TratamientoRESUMEN
From 2015 to 2019, 9 patients underwent ultrasound-guided intranodal lymphangiography for the treatment of a chyle leak following thoracic outlet decompression surgery. Chyle leaks were identified by Lipiodol (Guerbet, Roissy, France) extravasation near the left supraclavicular surgical bed in all patients. The technical success rate of thoracic duct embolization was 67% (6 of 9), including fluoroscopic transabdominal antegrade access (n = 4) and ultrasound-guided retrograde access in the left neck (n = 2). Clinical success was achieved in 89% of patients (8 of 9). The mean interval from lymphangiography to drain removal was 6.6 days (range, 4-18 d). No patients had a chyle leak recurrence during clinical follow-up (mean, 304 d).
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Quilo/diagnóstico por imagen , Descompresión Quirúrgica/efectos adversos , Embolización Terapéutica , Linfografía , Conducto Torácico/diagnóstico por imagen , Síndrome del Desfiladero Torácico/cirugía , Adulto , Embolización Terapéutica/efectos adversos , Femenino , Humanos , Masculino , Persona de Mediana Edad , Valor Predictivo de las Pruebas , Estudios Retrospectivos , Conducto Torácico/lesiones , Síndrome del Desfiladero Torácico/diagnóstico por imagen , Factores de Tiempo , Resultado del Tratamiento , Adulto JovenRESUMEN
Treatment of thoracic duct leaks can be very challenging. Intractable chlye leaks may require image-guided methods to increase the likelihood of treatment success. Near infra-red fluorescence is an easy-to-use nonionizing imaging method that has been described to detect thoracic duct leaks in open surgery or thoracoscopic interventions, yet no application to percutaneous sclerotherapy has been described. The authors suggest near infra-red fluorescence as a feasible and useful tool to guide percutaneous sclerotherapy.
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Quilotórax/etiología , Quilotórax/terapia , Imagen Óptica/métodos , Complicaciones Posoperatorias/terapia , Escleroterapia/métodos , Conducto Torácico/lesiones , Anciano , Quilotórax/diagnóstico por imagen , Doxiciclina/administración & dosificación , Humanos , Masculino , Soluciones Esclerosantes/administración & dosificación , Resultado del TratamientoRESUMEN
La fístula linfática cervical se produce por daño iatrogénico del conducto torácico en cirugías de cabeza y cuello. Ante la sospecha de una fístula linfática se debe iniciar rápidamente un manejo nutricional y seguimiento estrecho, ya que pueden tener consecuencias graves como inmunosupresión, compromiso metabólico y necrosis cutánea con exposición e incluso ruptura carotídea. A continuación se presenta el caso de un paciente con fístula linfática cervical que precisó reintervención quirúrgica para lograr el cese de la fístula
Chyle leak formation is produced by iatrogenic damage to the thoracic duct in head and neck surgeries. Given the suspicion of a cervical chyle leak, nutritional management and close follow-up should be initiated quickly, since they can have serious consequences such as immunosuppression, metabolic compromise and skin necrosis with exposure or even carotid rupture. We report the case of a patient with cervical chyle leak that required surgical reexploration to reach the chyle leak closure
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Humanos , Masculino , Persona de Mediana Edad , Fístula/cirugía , Traumatismos del Cuello/cirugía , Conducto Torácico/lesiones , Neoplasias Mandibulares/cirugía , Fístula/diagnóstico por imagen , Enfermedad Iatrogénica , Neoplasias Mandibulares/complicaciones , Drenaje Linfático Manual , Biopsia/métodosRESUMEN
INTRODUCTION: Chyle leaks following surgery to the axilla are seldom encountered with an incidence <0.7%. Management varies with no consensus in the literature. Injury to branching tributaries of the thoracic duct may require lengthy management at significant cost to patient and clinical team. This paper aims to provide an up-to-date review to support clinical management. METHODS: The term 'chyle' was combined with 'breast' or 'axilla.' EMBASE, Medline and PubMed database searches were conducted. All papers published in English were included with no exclusion date limits. RESULTS: 51 cases from 31 papers. All were female (mean age = 53.3yrs). 47/51 leaks were left-sided. 5/51 underwent sentinel node biopsy, 19/51 level II axillary node clearance (ANC), 23/51 level III ANC, 5/51 not specified. 59% (30/51) of leaks were identified within 2 postoperative days (mean = 3.3days). 96% initially managed conservatively: Drain = 38/51; low-fat diet = 34/51; compression bandaging = 20/51; Aspiration = 6/51. 40/51 (78%) were successfully managed conservatively, 11 patients returned to theater for secondary management. 7/11 recorded volumes >500mls/24 hrs before secondary surgery. Mean resolution time from initial surgery was 17.3days (range = 4-64days). No statistically significant difference (p = 0.72) in time to resolution between conservatively and surgically managed patients. CONCLUSIONS: Chyle leaks are rarely seen following axillary surgery. Aberrant thoracic duct anatomy represents the likeliest aetiology. We advocate early recognition and tailored individual management. Conservative management with non-suction drainage, low-fat diet and axillary compression bandaging appear effective where output <500ml/24 hrs. Secondary surgical management should be considered in high chylous output (<500mls/24 hrs) patients unresponsive to conservative measures. We propose a management algorithm to aide clinicians.
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Ascitis Quilosa/terapia , Manejo de la Enfermedad , Drenaje/métodos , Escisión del Ganglio Linfático/efectos adversos , Complicaciones Posoperatorias/terapia , Conducto Torácico/lesiones , Ascitis Quilosa/etiología , Salud Global , Humanos , Incidencia , Complicaciones Posoperatorias/epidemiología , Complicaciones Posoperatorias/etiologíaRESUMEN
OBJECTIVE: Cisterna chyli is a pearl-shaped elongated lymphatic structure located at the level of L1-L2 vertebra just beneath the aorta (Hsu and Itkin, 2016 [1]). It receives lymphatic drainage of intestines and lower body structures (Loukas et al., 2007 [2]). Size, shape and location are all highly variable and in some autopsy series CC was identified in only half of the cases (Song, 2016 [3]). During the laparoscopic paraaortic lymphadenectomy inadvertent injury to otherwise unidentified CC could lead to refractory chylous ascites (Favero et al., 2010 [4]). The objective of this video is to demonstrate the anatomic localization and consequences of inadvertent injury to CC in laparoscopic paraaortic lymphadenectomy. METHODS: Two different patients undergoing laparoscopic paraaortic lymphadenectomy were presented. RESULTS: The first case is a 51â¯year old woman with grade III endometrioid adenocarcinoma of uterus who was subjected to laparoscopic staging (laparoscopic hysterectomyâ¯+â¯BSOâ¯+â¯pelvic and paraaortic lymphadenectomy). Intraoperatively an injury to cisterna chyli occurred which was sealed and repaired immediately. The second case is a woman with stage IIB clear cell cervical cancer undergoing laparoscopic staging (pelvic and paraaortic lymphadenectomy). In this case cisterna chyli could be recognized and preserved. CONCLUSION: Cisterna chyli is an important anatomic structure which should be identified and preserved during laparoscopic paraaortic lymphadenectomy. Any iatrogenic injury to cisterna chyli could lead to chylous ascites and indeed in minority of these cases surgical intervention is required.
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Laparoscopía/efectos adversos , Escisión del Ganglio Linfático/efectos adversos , Conducto Torácico/lesiones , Carcinoma Endometrioide/cirugía , Neoplasias Endometriales/cirugía , Femenino , Humanos , Histerectomía/efectos adversos , Histerectomía/métodos , Laparoscopía/métodos , Escisión del Ganglio Linfático/métodos , Persona de Mediana Edad , Estadificación de NeoplasiasRESUMEN
No disponible
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Humanos , Masculino , Persona de Mediana Edad , Quilo , Conducto Torácico/lesiones , Fístula/cirugía , Conducto Torácico/cirugía , Neoplasias de la Lengua/cirugía , Complicaciones Posoperatorias/terapia , Nutrición Parenteral , Somatostatina/uso terapéutico , Toracoscopía/métodosAsunto(s)
Quilotórax/terapia , Edema/etiología , Embolización Terapéutica , Traumatismos del Cuello/terapia , Dolor de Cuello/etiología , Conducto Torácico/lesiones , Adulto , Quilotórax/diagnóstico por imagen , Quilotórax/etiología , Femenino , Humanos , Traumatismos del Cuello/diagnóstico por imagen , Traumatismos del Cuello/etiología , Conducto Torácico/diagnóstico por imagen , Resultado del TratamientoAsunto(s)
Angioplastia Coronaria con Balón/normas , Procedimientos Quirúrgicos Cardíacos/efectos adversos , Disnea/etiología , Derrame Pleural/diagnóstico , Derrame Pleural/terapia , Conducto Torácico/lesiones , Conducto Torácico/cirugía , Preescolar , Ecocardiografía Tridimensional , Femenino , Humanos , Pulmón/diagnóstico por imagen , Guías de Práctica Clínica como Asunto , Toracocentesis , Resultado del TratamientoRESUMEN
A chylothorax, also known as chylous pleural effusion, is an uncommon cause of pleural effusion with a wide differential diagnosis characterized by the accumulation of bacteriostatic chyle in the pleural space. The pleural fluid will have either or both triglycerides >110â¯mg/dL and the presence of chylomicrons. It may be encountered following a surgical intervention, usually in the chest, or underlying disease process. Management of a chylothorax requires a multidisciplinary approach employing medical therapy and possibly surgical intervention for post-operative patients and patients who have failed medical therapy. In this review, we aim to discuss the anatomy, fluid characteristics, etiology, and approach to the diagnosis of a chylothorax.
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Quilotórax/etiología , Derrame Pleural/patología , Conducto Torácico/lesiones , Antineoplásicos Hormonales/uso terapéutico , Quilotórax/diagnóstico por imagen , Quilotórax/terapia , Diagnóstico Diferencial , Exudados y Transudados/química , Exudados y Transudados/citología , Exudados y Transudados/metabolismo , Humanos , Linfografía/métodos , Linfocintigrafia/métodos , Octreótido/uso terapéutico , Periodo Posoperatorio , Radiografía Torácica/métodos , Succión/métodos , Toracocentesis/métodos , Conducto Torácico/diagnóstico por imagen , Conducto Torácico/fisiopatología , Conducto Torácico/cirugía , Tomografía Computarizada por Rayos X/métodos , Triglicéridos/análisisRESUMEN
Injury to the thoracic duct with resultant chylothorax can cause significant patient morbidity and mortality. Conservative treatment strategies often fail to address the problem. Open surgical and percutaneous approaches are often required to manage patients with refractory chylothorax. This review describes in detail the major role of minimally invasive interventional therapies for thoracic duct (TD) injury. The review emphasizes strategies for identifying the TD on preprocedural imaging and describes various techniques for percutaneous access to the TD. The advantages and disadvantages of several approaches for accessing the duct are discussed. The technique of duct embolization is highlighted. The role of the minimally invasive percutaneous approach over open surgical approaches is discussed with a review of clinical outcomes, as reported in the literature. This review will also briefly discuss the surgical approach to TD ligation.
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Quilotórax/terapia , Embolización Terapéutica/métodos , Conducto Torácico/lesiones , Tomografía Computarizada por Rayos X/métodos , Quilotórax/diagnóstico por imagen , Humanos , Conducto Torácico/diagnóstico por imagenRESUMEN
INTRODUCTION: Chylothorax is a rare cause of pleural effusion. The most common causes are iatrogenic or medical. We report an unusual and rare cause of bilateral chylothorax. CASE REPORT: A 73-year-old woman with no past history was admitted to the emergency department for sudden onset of dyspnoea. Chest X-ray and thoracic CT scan revealed large bilateral pleural effusions. Analysis of the fluid revealed a chylothorax. The patient was treated by chest tube drainage and a fat free (medium chain triglyceride) diet. This led to drying up of the effusions and rapid discharge. Complementary imaging examinations with chest-abdomen-pelvis CT, PET CT and pelvic MRI did not reveal any underlying cause. The final diagnosis was bilateral traumatic chylothorax caused by tearing of the thoracic duct during stretching exercises. CONCLUSION: Following a literature review, similar cases with the same clinical presentation were found. Combined treatment with thoracic drainage and medium chain triglyceride diet was effective in drying up the effusions. Our diagnosis was a diagnosis of exclusion. It is important to exclude a medical cause by thorough investigation.
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Quilotórax/etiología , Ejercicios de Estiramiento Muscular/efectos adversos , Conducto Torácico/lesiones , Anciano , Femenino , HumanosRESUMEN
Background. Chylothorax is a rare but severe complication after esophagectomy with an incidence of 1.9% to 8.9%. The aim of this study was to evaluate the efficacy of intraoperative lipid-rich feeding in reducing the incidence of post-esophagectomy chylothorax. Methods. A retrospective cohort study was performed among patients who underwent totally minimally invasive esophagectomy with intrathoracic anastomosis (tMIE Ivor Lewis) from February 2015 until December 2016. In this group, a lipid-rich solution was administered intraoperatively via a feeding jejunostomy. A historical cohort of identical patients operated in the period December 2012 to February 2015 did not receive intraoperative feeding and was used as a control. Results. In total, 133 patients underwent tMIE Ivor Lewis, of whom 59 patients (44%) received lipid-rich solution intraoperatively. The administered median total volume was 800 mL. During thoracic dissection, the thoracic duct was clearly visible in 37 patients (63%). With the help of lipid-rich feeding, intraoperative unintended duct damage was detected in 3 patients and treated. Postoperatively, 1 out of 59 patients (1.7%) developed chylothorax that was managed nonoperatively. In the control group, chylothorax was seen in 3 out of 74 patients (4.1%), P = .629. Conclusions. Intraoperative lipid-rich solution through a feeding jejunostomy helps identify thoracic duct damage during tMIE and may reduce postoperative chylothorax.